Healthcare Provider Details

I. General information

NPI: 1568572907
Provider Name (Legal Business Name): SOUTH SUBURBAN EAR, NOSE & THROAT ASSOC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 03/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 MAIN ST
SOUTH WEYMOUTH MA
02190-1659
US

IV. Provider business mailing address

825 MAIN ST
SOUTH WEYMOUTH MA
02190-1659
US

V. Phone/Fax

Practice location:
  • Phone: 781-337-3424
  • Fax: 781-337-7569
Mailing address:
  • Phone: 781-337-3424
  • Fax: 781-337-7569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID B RUDOLPH
Title or Position: PRESIDENT
Credential: MD
Phone: 781-337-7635